Pathology/Lab Coding Alert

Count on specificity, 2017 code change awareness.

You may recall how relieved you were when you heard that CMS gave you a year-long “free pass” on claim denials as long as you got your lab’s ICD-10-CM codes to the proper family. Now you should recall that specific diagnosis coding is coming home to roost when the grace period ends Oct. 1, 2016.

Alert: The end of the grace period may result in an increase in denials if you haven’t been applying the level of specificity ICD-10 truly requires, says ICD-10 trainer Monica Smith, RHIT, CPC, CRCR, an associate in Kraft Healthcare Consulting’s compliance services division.

Between the sunset of claims leniency and the recent release of the final ICD-10-CM 2017 addenda (effective Oct. 1), you need to make sure you’re ready to report timely and complete diagnosis codes on every claim.

Specificity is Key to Avoid Denials

Make sure you always assign an ICD-10 code based on the most specific, certain diagnosis available to you. According to coding guidelines, you should not “code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ or ‘working diagnosis’ or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

In other words, you should code the final diagnosis or results of the test if available, rather than the symptom that led to the performance of the test. However, coding signs and symptoms is acceptable to support medical necessity for the ordered tests when there is not a definitive diagnosis available. If you have a final diagnosis, don’t additionally report symptoms that are integral to the disease process.

Lab note: For clinical lab tests, you’ll generally report the ICD-10 code for the signs, symptoms, or conditions that the ordering physician provides when requesting the test. The lab will report the test results to the ordering physician, who then uses that information along with clinical data to assign the final diagnosis, which the lab may never see.

Pathology tip: Because the pathologist often assigns the definitive diagnosis based on a procedure such as a surgical pathology exam, you should use the completed pathology report to assign the final diagnosis.

Avoid ‘truncated’ codes: If you report a code that doesn’t include the full range of digits required to be a complete code, that’s called a truncated code — and that’s bad. If the code requires a fourth, fifth, sixth, or seventh digit, you can’t just leave off the extra digits because you don’t have specific information. Most categories that require extra digits include NOS or NEC codes that you can use if you don’t have more specific information.

Do this: Always report ICD-10 codes to the highest level of specificity required. If you report a truncated code, don’t be surprised by a claim denial for lack of medical necessity.

Especially now: You can expect denials starting Oct. 1 for claims that don’t list the ICD-10 code to the most accurate, complete level — even if the claim would have passed muster during the grace period.

Prep Now for ICD-10 2017

Even if your coding and documentation were perfect in 2016, you’ll need to put in some work to be sure you can maintain your accuracy rate once the 2017 changes go into effect.

“Educate and train on the 2017 ICD-10 CM changes,” says Marchelle Cagle, CPC, CPC-I, PCS, of Cagle Medical Consulting in Birmingham, Ala.

Also ensure that you’ve ordered your 2017 ICD-10 CM books, Cagle says.

Resources: The ICD-10 CM changes are also published here: www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html. Plus, “there are many free webinars out right now to ensure a practice gets ICD-10 CM change training,” Cagle adds.

Tip: To see some lab and pathology changes you need to know for 2017, review “Jump On Diagnosis Changes Coming This October” in Pathology/Lab Coding Alert vol. 17 no. 7 .